CUIDADO É FUNDAMENTAL
UNIVERSIDADE FEDERALDO ESTADODO RIODE JANEIRO. ESCOLADE ENFERMAGEM ALFREDO PINTO
RESEARCH DOI: 10.9789/2175-5361.rpcfo.v12.8964
CUIDADO É FUNDAMENTAL
UNIVERSIDADE FEDERALDO ESTADODO RIODE JANEIRO. ESCOLADE ENFERMAGEM ALFREDO PINTO
R E V I S T A O N L I N E D E P E S Q U I S A
NURSING RECEPTION IN THE ADMISSION OF CHRONIC
RENAL PATIENT FOR HEMODIALITIC TREATMENT
Acolhimento do enfermeiro na admissão do paciente renal crônico para
tratamento hemodialitico
Acogida del enfermero en la admisión del paciente renal crónico para
tratamiento hemodialitico
Shirley Sotero da Silva Sousa1, Sayonnara Ferreira Maia2, Flávia Dayana Ribeiro da Silveira3, Fábio dos Santos Gomes4, Jeciane Maria Pires de Sousa5, Polyanna Pereira da Silva6
How to cite this article:
Sousa SSS, Maia SF, Silveira FDR, Gomes FS, Sousa JMP, Silva PP. Nursing reception in the admission of chronic renal patient for hemodialitic treatment. Rev Fun Care Online. 2020 jan/dez; 12:603-608. DOI: http://dx.doi.org/0.9789/2175-5361.rpcfo.v12.8964.
ABSTRACT
Objectives: to analyze how the chronic renal patient receives for the hemodialytic treatment by the nurse
on admission to a Hemodialysis clinic. Method: Exploratory descriptive study with a qualitative approach, carried out in September and October 2018. The study participants were 16 nurses who had been working for at least six months in the area of hemodialysis, and excluded those who did not provide direct assistance to the patient. Results: The nurses show that nurses perform routine bureaucratic procedures at admission, identify care needs related mainly to access, guide self-care, and have many patients under their supervision, making it difficult to perform complete care. Conclusion: the act of welcoming is performed in the search for the construction of the professional-patient bond, orienting to self-care, showing ways of adapting to the new treatment and its reflection on the patient’s quality of life.
Descriptors: Evaluation; Kidney Transplantation; Nursing. RESUMO
Objetivos: analisar de que forma ocorre o acolhimento do paciente renal crônico para o tratamento hemodialitico pelo enfermeiro
na admissão em uma clínica de Hemodiálise. Método: Estudo descritivo exploratório de abordagem qualitativa, realizada nos meses de setembro e outubro de 2018. Os participantes do estudo foram 16 enfermeiros que atuavam há pelo menos seis meses na área de hemodiálise, e excluídos os que não realizam assistência direta ao paciente. Resultados: As falas evidenciam que os enfermeiros executam procedimentos burocráticos rotineiros na admissão, identificam as necessidades de cuidado relacionados principalmente ao acesso,
1 Federal University of Piauí (UFPI), nurse, Master of Nursing 2 Piauis Higher Education Association (Aespi), Nurse 3 Federal University of Piauí (UFPI), nurse, Master of Nursing 4 Piauis Higher Education Association (Aespi), Nurse
orientam para o autocuidado e que tem muitos pacientes sob sua supervisão dificultando a realização de uma assistência completa. Conclusão: o ato de acolher é executado, na busca da construção do vínculo profissional-paciente, orientando ao auto cuidado, mostrando formas de adaptação ao novo tratamento e o seu reflexo na qualidade de vida do paciente.
Descritores: Avaliação; Transplante de Rim; Enfermagem.
RESUMÉN
Objetivos: analizar de qué forma ocurre la acogida del paciente renal
crónico para el tratamiento hemodialitico por el enfermero en la admisión en una clínica de Hemodiálisis. Método: estudio descriptivo exploratorio de abordaje cualitativo, realizado en los meses de septiembre y octubre de 2018. Los participantes del estudio fueron 16 enfermeros que actuaban hace al menos seis meses en el área de hemodiálisis, y excluidos los que no realizan asistencia directa al paciente. Resultados: las declaraciones evidencian que los enfermeros realizan procedimientos burocráticos rutinarios en la admisión, identifican las necesidades de cuidado relacionadas principalmente con el acceso, orientan al autocuidado y que tiene muchos pacientes bajo su supervisión dificultando la realización de una asistencia completa. Conclusión: el acto de acoger es ejecutado, en la búsqueda de la construcción del vínculo profesional-paciente, orientando al auto cuidado, mostrando formas de adaptación al nuevo tratamiento y su reflejo en la calidad de vida del paciente.
Descriptores: Evaluación; Trasplante de Riñón; Enfermeria.
INTRODUCTION
Chronic Kidney Failure (CKD) is an advanced kidney disease with a gradual and irreversible loss of kidney function making it impossible for the kidneys to perform their basic functions, leading to death if left untreated. Causes are usually associated with Hypertension, Glomerulopathies, Malformations, Diabetes, Hereditary
Diseases, and Autoimmune Diseases.1
In Brazil, more than 126,000 people have terminal chronic kidney disease and are in some form of dialysis treatment. It is estimated that about 35,000 new patients enter the dialysis program each year. In addition, the mortality rate
is high due to concomitant cardiovascular complications(2).
With the functional disability of the kidney, toxic waste that should be excreted accumulates in the bloodstream, causing various organ dysfunctions such as anemia, bone weakening, neuropathy, heart disease, nutrient metabolism disorders, leading to malnutrition, hormonal dysfunction, gastrointestinal tract diseases, thus compromising the quality of life of patients.
CRF treatment modalities for partial replacement of renal functions are dialysis and kidney transplantation, and dialysis is subdivided into peritoneal and hemodialysis. These treatments extend the life of the patient, but do not bring cure of the disease. Chronic renal failure is related to decreased filtration rate associated with loss of endocrine and excretory regulatory functions of the kidneys. The forms of treatment for chronic renal failure are peritoneal dialysis, hemodialysis and kidney transplantation.
After the diagnosis of chronic kidney disease (CKD), the patient should undergo conservative or dialysis treatment as soon as possible; since treatment is essential for survival(3).
Hemodialysis treatment is usually initiated in an emergency of chronic kidney disease, when the patient is
normally hospitalized(4). The nurse assisting the patient in
hemodialysis has some duties and is responsible for dressing; ensuring the correct use of materials and equipment, guiding, supervising and evaluation of care provided by the team to ensure environmental safety and patient comfort; prevention, identification and treatment of the adverse effects of hemodialysis and the complications arising from the disease itself; educational actions aimed at quality and efficiency of treatment for the patient’s quality of life(5).
The reception of the person with kidney disease in the hemodialysis treatment is the responsibility of the nurse, because he/she has the best knowledge of the person and the context, establishing a link, a relationship of proximity, permanent presence, with each experience of receiving the patient flexible and adjusted adjustable depending on clinical situation of each patient’s(6).
The chronic kidney patient suffers with several changes in their daily life and is dependent on trained professionals
who provide care and contribute to their quality of life(3).
Thus, we aimed to analyze how chronic renal patients are received for hemodialysis treatments by nurses upon admission to a Hemodialysis clinic.
METHODOLOGY
This is a descriptive study with a qualitative approach, conducted in a nephrological clinic in the state of Piauí. The clinic where the survey was conducted treats 554 patients monthly, offering peritoneal dialysis, hemodialysis, and conservative outpatient treatment. It has a peritoneal dialysis room, five hemodialysis rooms; opens Monday to Saturday, in the mornings, afternoons and evenings; 50 patients were treated daily in HD each shift, totaling 150 clients on daily hemodialysis treatment. The clinic has 65 hemodialysis machines in operation, and the patients are attended by a nursing team, consisting of 56 nursing technicians and 18 nurses divided into 3 shifts.
All nurses (18) were invited to participate in the study, however two refused. Thus, those who have been working for at least six months with hemodialysis treatments were included, and those who did not provide direct patient care, i.e. occupied administrative positions and similar, were excluded.
For data collection, an instrument with semi-structured questions was used, covering questions about reception, based on previous literature review. The form was submitted for validation by an odd number of judges. Data collection was performed on the premises of the clinic itself in a
closed room. They were recorded on a mp4 device, had an average duration of 25 minutes and were performed by the researchers themselves.
For data analysis and interpretation, an approximation was made with the content analysis based on Bardin
(2004)(7). As this was a study involving human beings,
the project of this research was submitted to and approved by the Research Ethics Committee of the Piauí Higher Education Association (AESPI).
RESULTS
The majority of sample were female patients (87.5%), aged between 25 and 53 years old, married or in a stable union (62.5%), with more than six years of experience in hemodialysis (8.5%) with graduate degrees (100%).
Content analysis of the interviews made it possible to understand how reception occurs in the admission of patients with chronic kidney disease for hemodialysis treatment, identifying the actions of the nursing professional and the importance of reception in the admission of this patient; difficulties in doing so and suggestions for improving this process.
Reception of chronic renal patients on
admission for hemodialysis
The nurses expressed that they perform the reception at the moment of admission of the patient with CKD, conduct the anamnesis and the physical examination in the patient. Initial guidance is also provided regarding service routines and self-care with access to hemodialysis (fistula or catheter). If the patient does not have access to hemodialysis yet, the nurse provides the necessary resources for the implantation of the double lumen catheter by the nephrologist.
If the client has a catheter, its integrity and functionality are evaluated, observing whether it presents phlogistic signs, bleeding or reports of fever and / or chills, in which case the dressing is replaced; providing, if necessary, the passage of a new CDL by the nephrologist, explaining to the patient and / or companion the care they should have with the catheter, and the importance of maintaining full and functioning access maintaining its dressing clean and dry.
If the patient has AVF, its maturity is observed and if the thrill is present explaining the precautions necessary to maintain its integrity as well as how to correct limb hygiene before puncture and what are the signs of inflammation noted.
[...] when the patient arrives, I take them to the nursing office, I perform anamnesis physical examination, explain about the treatment, the necessary care, about the procedure that will be performed, in this case the catheter. [E13]
[...] when the patient arrives, he is soon seen if he has a catheter or fistula; if necessary, we guide and prepare the patient for the catheter [...] passage, we share the necessary and basic guidelines regarding the treatment, the accesses [...] regarding the days, what are the days, the duration of the treatment, the importance of not missing, right [...] we do the physical exam. [E9] [...] the patient receives a sheet with the clinic’s rules and important information, about the arrival time at the clinic [...] it is until what time they can arrive for the treatment [...] change appointment time, who is entitled to a companion [...] what can enter the hemodialysis room and what cannot [...] and should weigh before and after hemodialysis [...] E11
The patient is advised about their fluid intake and diet, informed about the risks of interdialytic excessive weight gain and possible complications during or after HD. In addition the patient is referred to the nutritionist for better assessment and dietary guidance.
The importance of the treatment and its attendance, the duration and the days of each session are explained to the patient and their family members, and it was noticed that the companion or family present also receive the same information, always being involved in the care process.
[...] I always talk to the patient and his companion, we always talk about it [...] that the treatment, right [...] aims to improve the quality of life, that it is a treatment that replaces the function of the patients’ kidneys [...] and the time he will spend here in each session [...] E4 [...] there are patients who are already aware of the treatment, there are others who sometimes do not accept the treatment [...] then there has to be a lot of talk, day by day so that they can get used to the idea that they need hemodialysis for the rest of life [...] E13
Another situation verified in the nurses’ statements was regarding the humanization in the initial reception, the importance of understanding the sensitivity and fragility of the patients’ situation, and the intention of the approaching professional to be available for any patients’ needs.
“[...] as a nurse, I believe that a well-managed reception softens some situations, right? It is important to earn the trust of the patient and the family [...] and to pass trust is important [...] ”E12.
“[...] we always make the necessary orientations, [...] clear all doubts, because when patients arrive here, they come with a lot of insecurity [...]” E4
[...] I think the first contact is important, because from there we develop a relationship of trust with the patient, many of them come from the countryside, and will come to the treatment, three times a week, we kind of become a “family” of them [...] E7
[...] in the first session, patient feels distressed, everything is very new to him, sometimes he gets sick, develops headache, vomiting, cramps, so it is important that we are present, to intervene soon. [...] E9
During the interview, the nurses mentioned that in the clinic there was a protocol to be followed from the admission of the patient to the connection and disconnection of the hemodialysis machine. However, other statements demonstrate ignorance of this document.
[...] In the clinic we have a document that we call protocol [...] with norms and routines of the clinic, and there is the sequence, right, from the patient’s arrival to the clinic, from admission, reception, right, to treatment. [...] E6 [...] what we do is his SAE, to take it, the risks he has, the nursing diagnoses but protocol really to follow as soon as he arrives, we don’t have [...] E13
[...] when he arrives, I perform the anamnesis and the physical exam, I try to get to know the patient’s reality, clarify the doubts he has, I do the SAE, to see the patient’s diagnoses and risks [...] E10
Difficulties encountered while treating
Normally there are complications during the hemodialysis session, therefore, the presence of nurses uninterruptedly during the period of the session is of paramount importance, both to reduce the occurrence of complications and to reduce the risk of greater harm to patients. A bond of trust and security are important aspects that nurses must develop in the interpersonal relationship with the patient.
The nurses’ statements expressed that sometimes, the reception, as idealized by them, did not happen due to the huge demand for a nurse and that they had many complications during each hemodialysis session, causing the nurse to concentrate in meeting these demand first.
[...] there are so many patients and sometimes there are complications so I can’t offer the right reception in the first session [...] E17
[...] there are many patients, but I can’t do anything, the new ordinance says there are 50 patients for a nurse [...] how can I provide quality care this way? [...] E18 [...] it would be ideal if we had more professionals, so we could assist patients with quality [...] E14
[...] my difficulty is to manage to follow so many patients [...] not to mention the complications that happen, just when I’m with a new patient [...] happened to have three patients feeling sick at the same time [...] then it is difficult, right, giving quality care [...] E 12
The statements also show that the presence of a multidisciplinary team in welcoming the patients on admission is important; because there are many guidelines. The clinic has a social worker, a psychologist, and a nutritionist, thus composing with the nursing and medical team the multidisciplinary team.
[...] both the doctor, the nurse and the technician; I think it’s the three professionals who can have this direct contact on the first day; on admission and guidance, the other nutritionist and psychologist professionals can get this contact later, they don’t always get it right now; then I think that is missing more; improve this reception by the team as a whole [...] E11
[...] many times they start the treatment, with the head at a thousand [km/h] right; they don’t want to, they have that refusal to accept that they are sick and need treatment [...] E16
[...] a nutritional assessment, regarding what can and cannot [...] restrict fluid, we are the nurse who is sharing these first guidelines, for having this first contact with them [...] ] so my suggestion for improvement would be in this sense [...] because patients need these guidelines [...] so on admission of a patient it would be more appropriate for him to go through the entire team before starting treatment [...] E 10
The clinic offers a multi-professional team to meet the demand of patients but the nutritionist, psychologist and social worker are not available for care at all times.
The presence of these professionals was not reported during the patient’s admission process. This part of the team would have later contact with the patient; by prior appointment; at times and days sometimes unfeasible for patients who mostly reside in the interior of the state
DISCUSSION
Being a carrier of a chronic disease is a major challenge due to changes in lifestyle, diet and daily life, continuous use of medicines and dependence on people and equipment, requiring an adaptation to the new way of life. We observed the actions performed by the nurse in welcoming this patient, during anamnesis and physical examination, with the objective of providing comfort and safety to the patient from the very first moment.
The findings demonstrate that the actions performed by nurses who took part in this study were designed to allow approximation between professional and patient, based on the format in which the patient presents a complaint and stemming from this, a further conduct is defined.
In this sense reception is very much like the nursing care, since both involve the establishment of interpersonal relationships aiming to provide comfort and recognition that the patient is endowed with objective and subjective
conditions stemming from his/her life context(8-9).
A point cited as important was precisely the impact of the first contact with the patient / family and its reflection on the attendance and acceptance of treatment; the building of bonds, the humanization, the feeling of confidence in the professional as well as the procedures and orientations shared regarding the treatment, as reinforced by the literature(3,10).
Our results indicate team communication failures, since there are disagreements among nurses’ statements regarding the existence of a protocol in the clinic to be followed; a basis such as a flowchart in the patient’s admission process that maps the activities to be performed and guidelines to be shared before the patient’s first session of hemodialysis treatmen (11-12).
Nursing Care Systematization (SAE) is another crucial point for the effectiveness of care. The SAE is considered a care management tool that involves aspects that transcend direct care, enabling the evaluation of the efficiency and effectiveness of the activities performed and contributing
to decision making aiming at the excellence of care(9).
However, care is guided by anamnesis and physical examination of the patient, not contemplating all stages of the process.
Complications during hemodialysis were identified as the main obstacles for effective reception at admission. The number of patients makes it impossible to provide quality care, whereas such expectations could be met if the team were scaled up for quality nursing care(8,11-14).
beyond the nurse’s competence. He/she needs nutritional, psychological and social support, therefore the presence of a multidisciplinary team aiming to meet this need in the first contact of the patient to treatment is very positive.
CONCLUSION
The act of reception is designed to build the bond between the professionals and their patients, provide guidance on self-care, showing ways of adapting to the new treatment and its impacts on the patient’s quality of life.
We found that the reception of the patient newly admitted to hemodialysis conducted by the nurse has a motivating impact both in terms of the acceptance of treatment and its attendance. This in turn has direct relationship with the improvement of life considering the challenges faced by the patients.
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Received in: 21/05/2019 Required revisions: Did not have Approved in: 02/10/2019 Published in: 01/06/2020
Corresponding author
Sayonnara Ferreira Maia
Address: Rua 31 de Março, 2457, Bloco 2 Ap 402
Ininga, Teresina/PI, Brazil
Zip code: 64049-700 E-mail address: sayonnaramaia@hotmail.com Telephone number: +55 (86) 98819-4718
